Finding a migraine treatment that is effective and reliable, and information on how medications compare to one another, is lacking, say researchers, whose recent analysis suggests that certain migraine drugs like triptans, ergots and anti-emetics, may be two to five times more effective than ibuprofen.
The team, led by Rush University Medical Centre, Chicago, US, drew on data from nearly 300 000 people using a smartphone app to help consumers make decisions about their medications, and published their findings in Neurology, the medical journal of the American Academy of Neurology.
Migraine attacks are characterised by intense throbbing head pain, sensitivity to light and sound, nausea or vomiting, and can also be associated with cognitive issues, reports News-Medical.Net.
“There are many treatment options available to those with migraine. However, there is a lack of head-to-head comparisons of the effectiveness of these treatment options,” said study author Dr Chia-Chun Chiang of the Mayo Clinic Minnesota, and member of the American Academy of Neurology.
“These results confirm that triptans should be considered earlier for treating migraine, rather than reserving their use for severe attacks.”
The researchers included more than 3m migraine attacks from nearly 300 000 users that were self-reported by people using a smartphone app during a six-year period.
The app allows users to monitor the frequency of migraine attacks, triggers, symptoms and medication effectiveness.
For those migraine attacks, participants entered 4.7m treatment attempts with various medications into the app. They recorded whether a medication was helpful or not. The researchers then used that information to calculate the effectiveness of each drug compared with ibuprofen.
The team looked at a total of 25 medications among seven drug classes. Different dosages of medication and formulas of each medication were combined in this analysis.
The study found that the top three classes of medications more effective than ibuprofen were triptans, ergots and anti-emetics. Triptans were five times more effective than ibuprofen, ergots were three times more effective and anti-emetics were two and a half times more effective.
When looking at individual medications, the top three were eletriptan, which was six times more effective than ibuprofen, zolmitriptan, which was five and a half times more effective, and sumatriptan, which was five times more effective.
Researchers found that when using eletriptan, participants found it helpful 78% of the time. Zolmitriptan was helpful 74% of the time and sumatriptan was helpful 72% of the time.
Ibuprofen was helpful 42% of the time.
Researchers also looked at other groups of medication like acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs other than ibuprofen were 94% more effective than ibuprofen.
Participants found ketorolac helpful 62% of the time, indomethacin was helpful 57% of the time, and diclofenac was helpful 56% of the time. However, acetaminophen was helpful 37% of the time and found to be 17% less effective than ibuprofen when used for treating migraines.
Additionally, a common combination of medications used to treat migraine, aspirin, acetaminophen and caffeine, was also evaluated and found to be 69% more effective than ibuprofen.
“For people whose acute migraine medication is not working for them, our hope is that this study shows that are many alternatives that work,” said Chiang.
A limitation of the study was that evaluations of medications could be influenced by a user’s expectations of the drug or the dosage they took.
Another limitation was that newer migraine medications, gepants and ditans, were not included in the study due to the low amount of data when the study was conducted, and lack of availability in many countries.
The study was supported by the Kanagawa University of Human Services.
Study details
Simultaneous Comparisons of 25 Acute Migraine Medications Based on 10 Million Users’ Self-Reported Records From a Smartphone Application
Chia-Chun Chiang, Xuemin Fang, Zsolt Horvath, Francois Cadiou, Alexandre Urani, Weijie Poh, Hiroto Narimatsu, Yu Cheng, David Dodick.
Published in Neurology on 29 November 2023
Abstract
Background
Many acute treatment options exist for migraine. However, large-scale, head-to-head comparisons of treatment effectiveness from real-world patient experience reports are lacking.
Methods
This is a retrospective analysis of 10 842 795 migraine attack records extracted from an e-diary smartphone application between June 30, 2014, and July 2, 2020. We analysed 25 acute medications among seven classes- acetaminophen, NSAIDs, triptans, combination analgesics, ergots, anti-emetics, and opioids. Gepants and ditan were not included in this analysis. Different doses and formulations of each medication, according to the generic names, were combined in this analysis. We employed a two-level nested logistic regression model to analyse the odds ratio (OR) of treatment effectiveness of each medication by adjusting concurrent medications and the covariance within the same user. Subgroup analyses were conducted for users in the United States (US), the United Kingdom (UK), and Canada (CAN).
Results
Our final analysis included 4 777 524 medication-outcome pairs from 3 119 517 migraine attacks among 278 006 users. Triptans (mean OR 4.8), ergots (mean OR 3.02), and anti-emetics (mean OR 2.67) were the top three classes of medications with the highest effectiveness, followed by opioids (mean OR 2.49), NSAIDs (other than ibuprofen, mean OR 1.94), combination analgesics (acetaminophen/acetylsalicylic acid/caffeine) (OR 1.69, 95% CI 1.67-1.71), others (OR 1.49, 95% CI 1.47-1.50), and acetaminophen (OR 0.83, 95% CI 0.83-0.84), using ibuprofen as the reference. Individual medications with the highest ORs were eletriptan (OR 6.1, 95% CI 6.0-6.3), zolmitriptan (OR 5.7, 95% CI 5.6-5.8), and sumatriptan (OR 5.2, 95% CI 5.2-5.3). The ORs of acetaminophen, NSAIDS, combination analgesics and opioids were mostly around or less than 1, suggesting similar or lower reported effectiveness compared to ibuprofen. The ORs for 24 medications, except that of acetylsalicylic acid, achieved statistical significance with p <0.0001, and our nested logistic regression model achieved an area under the curve (AUC) of 0.849. Country-specific subgroup analyses revealed similar ORs of each medication and AUC (US 0.849, UK 0.864, and CAN 0.842), demonstrating the robustness of our analysis.
Discussion
Using a big-data approach, we analysed patient-generated real-time records of 10m migraine attacks and conducted simultaneous head-to-head comparisons of 25 acute migraine medications. Our findings that triptans, ergots and anti-emetics are the most effective classes of medications align with the guideline recommendations and offer generaliseable insights to complement clinical practice.
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